Healthcare

RESEARCH JUSTIFICATION

Understanding the structure and trends of Scotland’s National Health Service is crucial to ensure equitable healthcare. The system currently faces increasing pressures from workforce shortages and an aging population which increase the demand for services.

What are the main challenges facing healthcare in Scotland?

NHS Structure

The NHS is a UK wide organisation funded by taxpayers, providing free healthcare to all UK citizens. In 1999, healthcare responsibilities were devolved from the UK Government to the individual nations of the UK. Since then, the Scottish government has had full authority over healthcare policy and other health-relate decision making in Scotland. (Kelly Shuttleworth, Elspeth Nicholson, Institute for Governement “Devolution of NHS”, 2020).

NHS Scotland operates as a hybrid system, not fully centralised or decentralised. The Scottish Parliament is responsible for overarching decisions such as policy making and funding allocations, these are then implemented by regional boards across the country. (NHS, NHS “About NHS Scotland”, 2025).

There are 14 Regional Health Boards across Scotland, each responsible for the planning, delivery and improvement of healthcare services within their local area. These boards receive legislation and funding from the Scottish Government and have the authority to make decisions on how best to use their resources, allowing them to operate with a degree of autonomy. Supporting them are national boards, which offer specialist services and expertise. Individual hospitals and practices operate under the guidance and funding of their regional boards, delivering healthcare directly to the local population. (NHS, NHS “About NHS Scotland”, 2025)

However, the current system has faced criticism, with Scotland’s Auditor General, Stephen Boyle noting that “the mix of local, regional, and national patterns across Scotland makes decision making and accountability difficult” (Stephen Boyle, Healthandcare.scot “NHS Governance must be strengthened, says watchdog”, 2025). Boyle has also advocated for significant NHS reform, emphasising that “The delivery of NHS services must be reformed for Scotland’s health service to remain affordable and sustainable” (Stephen Boyle, 2025). He further highlighted that “the planning of healthcare in Scotland is becoming more complex and the Scottish government needs to ensure lines of accountability and decision-making are clear” (Stephen Boyle, 2025). This audit demonstrates that, although individual regional health boards operate independently, their scope is limited due to the systems top-heavy structure.

Strains on the NHS

Approximately 10–12% of the UK population purchase private health insurance, usually for supplementary cover, meaning most people rely entirely on the NHS. Although health expenditure is 10% of UK GDP, the NHS remains underfunded, overstretched, and overworked. The UK has just 3 doctors per 1,000 people, below the OECD average of 3.5, and one of the lowest numbers of hospital beds at 2.3 per 1,000 people, far below Germany’s 8. As demand rises, the system relies on rationing, resulting in long queues and waiting times (Diane Coyle, Healthcare as Social Infrastructure, 2022). With almost no spare capacity, the NHS was unable to absorb the shock of COVID-19 in 2020.

The pressure is particularly visible in primary care. Almost half (44.8%) of GP practices in Scotland report their future as “precarious” or “unsustainable” due to “unimaginable” workloads (Anna Colivicchi, Pulse “Nearly 160 sessional GPs currently ‘seeking work’ in Scotland alone”, 2025). This strain is caused by rising patient numbers alongside a fall in GP practices, from 1,000 in 2012 to 889 in 2024 (British Medical Association, “The sustainability crisis in GP practice in Scotland”, 2024). Financial pressure and a shortage of GPs have driven this decline, prompting the Scottish Government’s GP recruitment campaign in 2022 (Scottish Government, “Launch of GP recruitment campaign”, 2022).

Despite this, 160 unemployed full-time equivalent GPs remain. Funding these posts, just 1% of the annual NHS budget, could provide “approximately 700,000 additional appointments annually”, easing waiting times nationwide (Anna Colivicchi, 2025).

A resilient healthcare system should cope with both low and high demand, but years of cost-saving have discouraged investment in resilience. Instead, the NHS operates at the bare minimum, leaving it unable to withstand shocks such as the COVID pandemic, when the lack of reserve capacity triggered a scramble for staff, space, and resources.

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Location of A&E & MIU Departments, 30min travel time highlighted

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Case Study - Project CAELUS

Care and equity logistics UAS Scotland (CAELUS) is a healthcare innovation project utilising drone technology to create a network of medical delivery. The integration of drone technology within this project sets out to enhance the delivery of medical essentials efficiently throughout Scotland, addressing demographic changes, geographical challenges and workforce limitations.

In addition to delivering pharmaceuticals, this network proves a reduction time in transport for not only supplies but lab samples and bloods which can make significant changes to consultant and diagnostic time reaching medical conclusions faster (Innovate UK, CAELUS 2, accessed 2025).

Following a series of successful trials, which concluded in June 2024, test flights across Scotland demonstrated the potential of this technology. In one case, the journey between NHS Lothian and NHS Borders was reduced to 30 minutes, a journey that currently takes several hours by road (BBC News “Drones fly NHS lab specimens in Scottish first”, 2024). This successful demonstration of technological integration within Scotland’s healthcare system is a key step to improve the nations delivery and speed of healthcare.

Case Study - The Swedish Model

"To me it doesn't matter if the doctor is there physically or if we communicate via a screen. The most important thing for me is that it’s the same health professional who knows me, my illness and of course my treatment" – Patient Denmark, Healthcare At A Distance

Sweden’s healthcare model exemplifies a decentralised system, with each region operating with significant autonomy. Funding, structure and priorities are adapted to local needs (ExpoMedics, "How Healthcare in Sweden Works", 2021), which is essential in a country where population density ranges from approximately 367 people per km² to fewer than 5 people per km² in Vasterbotten (Official Statistics of Sweden, "Population density per sq.km, population and land area by region and sex. Year 1991 - 2024). This regional flexibility is particularly relevant to a nations like Scotland and Portugal, where geography and population distribution also vary widely.

Sweden’s national government plays only a limited role in setting guidelines and national priorities, while the 21 regional councils hold most decision-making authority (ExpoMedics, 2021). These councils organise, fund and deliver healthcare services, raising most revenue through local taxation, with central government grants supporting less affluent areas. Although Sweden charges small fees for medical care, they are minimal and capped at SEK 1,400 (approx. £111) per year. Regional boards diagnose complex conditions and, when necessary, refer patients to one of Sweden’s seven regional university hospitals.

The country’s 290 local municipalities provide a complementary layer of care by overseeing elderly services and social support (ExpoMedics, 2021).

In remote parts of rural Sweden, travel to the nearest hospital can take up to four hours by car. To mitigate this, regional systems increasingly use digital technologies to maintain access. Tools that allow professionals to “evaluate lab results, electro diagrams and even conduct emergency appointments remotely” help reduce unnecessary hospital visits (World Health Organization, "How digital health became the norm in Sweden's remote north: Sofie's perspective", 2023).

Dr Sophie Lyhammar, who works between Stockholm and Storuman, one of Sweden’s most remote areas, where resident doctors are rare, provides consistent, high-quality care through remote video consultations. During appointments, she connects with the virtual health room, where a nurse assists the patient and carries out procedures such as electrodiagrams, which Dr Lyhammar can examine in real time. This technology is now used to manage a wide range of conditions, ensuring patients travel to hospital only when necessary (World Health Organisation, "How digital health became the norm in Sweden's remote north: Sofie's perspective", 2023).

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NHS Reform

In 2025, NHS Scotland introduced two major strategic plans (NHS Scotland operational improvement plan and Scotland's Population Health Framework) to shift the system from a reactive model to one focused on prevention.

This responds to intensifying pressures, including poor population health (with two-thirds of people overweight), an ageing demographic, workforce shortages, and rising service demand. Together, these pressures have weakened the system’s ability to provide equitable access to care. The new strategies aim to secure the long-term sustainability of public services, reduce health inequalities, and make better use of digital innovation. As highlighted after the COVID-19 pandemic, “our resilience to future health threats is dependent on reducing health inequalities and creating environments where it is easier to live healthier lives” (NHS Scotland, NHS Scotland operational improvement plan, 2025) (NHS Scotland, Scotland's Population Health Framework, 2025).

This shift is informed by the Marmot Places framework, which “recognises that health and health inequalities are mostly shaped by the social determinants of health: the conditions in which people are born, grow, live, work and age, and takes action to improve health and reduce health inequalities”. It also stresses that those in the most deprived areas face disproportionate ill-health, with “higher rates of illness and shorter life expectancy – compared to those in more affluent areas” (Institute of Health Equity, Marmot Places, accessed 2025) (NHS Scotland, NHS Scotland operational improvement plan, 2025).

Reform is expected to be delivered mainly through local Health and Social Care Partnerships, working beneath regional boards and supported by the third sector. Established in 2016, HSCPs are intended to integrate health and social care and are well placed to respond to local needs. However, their ability to create meaningful change is limited by the NHS’s centralised structure. This was highlighted by Dr Alison Clement, Clinical Director of Angus HSCP, who described “huge issues with trying to get everyone to work together, to have the best utilsation of the space” (Dr Alison Clement, Interview with Ryan Smith on 14.11.2025), referring to difficulties coordinating with NHS Tayside and primary care services (NHS Scotland operational improvement plan) (Scotland's Population Health Framework).

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